I began my private practice in July of 2011, but almost a year before I began researching EHR systems.  I happened to do my medical school and residency training during the time when most health systems were transitioning to EHR in some form. In the space of 10 years, I used PowerChart (Hershey Medical Center), VISTA (VA), Medflow and GE Centricity (UNC-Chapel Hill), SRS and Epic (West Virginia University Eye Institute), along with a proprietary system at UNC Hospitals and several other systems while on away rotations.  I came to one conclusion: there is no perfect EMR and no one is completely pleased with the one they’ve chosen.  The amount of money being spent on these systems was mind-boggling, while our productivity seemed to falter under the weight of the increased charting, clicking, scrolling and logging in and out.  I could at least see 3 scenarios occurring with whatever system I settled on for my practice: 1. I’d pay a lot, but get what I paid for in a functional, easy to use EHR, optimized for my specific specialty that kept my practice and charts in good order and made my life a little easier (something I hadn’t yet see happen), 2. I’d pay a lot, then struggle to get the EHR to do what I want, spend lots of extra time and money customizing it and eventually just live with its imperfections (my experience with most EHRs), 3. I’d pay a lot, struggle with the system for a few years, then become so frustrated that I’d move on to a different system that promised to be everything the failed system wasn’t (my experience with a few EHRs).  In every case, I knew I’d be paying a lot, without any guarantee of which end result I’d have.  There had to be some alternative. 

In early 2011, I stumbled upon a review of a cloud-based EHR called Practice Fusion.  I was intrigued by the idea of storing all my charts in the cloud, where they would be accessible from any computer without having to keep software constantly updated on various machines.  I also liked the idea of not having to own and maintain a server or hire IT professionals.  The best part was, I could try all this for free, and if it worked out, it was still free.  My mother told me that anything that seems to good to be true probable is, and this seemed to good.  Well, in one sense it is too good to be true.  It isn’t the perfect EHR I was looking for, but I’m convinced that doesn’t exist.  What it is is good enough, and the fact that I’m not shelling out a fortune for the pleasure of using it allows me to forgive its few shortcomings.  I decided that as a new oculoplastic surgeon starting out, I could afford to test this system and see if it would work for me and my patients.

So test it we have.  We’ve been using it exclusively for over 9 months and here are my thoughts since then in the form of a Pros and Cons list.

Pros:

  1. Cost.  The system literally costs you nothing, unless you had no computer hardware in your office to start out.  I bought two all-in-one HP desktops to put in our exam rooms for $399 each.  They have a small footprint and are barebones.  All you need them for is a browser.  I have no other expenses directly relating to the EHR itself, with the exception of billing, which I’ll get to in a minute. 
  2. Accessibility.  I can’t stress enough how nice it is to be able to pull up my schedule, charts, photos, scanned documents and all other patient information from any location in the world. I have refilled prescriptions electronically while sitting on the couch on Saturday night, pulled up CT reports while up the canyon rock-climbing, and accessed phone numbers and insurance information while driving in the middle of nowhere in Southern Utah.  If you have ever stayed at the office to do something you could have done from home simply because that is where your charts or EHR reside, then you could benefit from this.
  3. Efficiency.  This is probably inherent in any EHR, but the reduced paper usage and filing have made my staff comment over and over how happy they are that we are using this system.  We don’t pull charts, we don’t put away charts, we don’t lose charts and we don’t save papers to file later.  We have a bin where any document related to patient goes, it gets scanned rapid-fire through our double-sided scanner (Fujitsu ScanSnap is awesome) and the paper is shredded.  When I get a referral, I type the response letter into Practice Fusion and fax it directly to my colleague.  I also am constantly adding and updating templates I use to make documentation faster.  You can easily create flowing templates that keep your most commonly used phrases easily accessible.  Scheduling is easy and if patients share their email, the system will send them automatic appointment reminders (something our patients love). 
  4. Meaningful Use.  Practice Fusion has a slick “Meaningful Use Dashboard”, which keeps track of all the criteria you must meet to qualify for your EHR incentive.  I can check at any time where we are and in real time tell my staff that they are not charting smoking status or medication lists.  We can stay on track easily, and when it is time to attest, all the numbers you must enter into the CMS website are right there.  It took me 20 minutes to attest after my first 90-day period and 7 weeks later I had a check for $18,000.  E-prescribing is also top-notch and very fast.  I hate writing out prescriptions that I’m worried no one can read.  And patients love getting to the pharmacy and finding their Rx already filled.
  5. Integration of older patient data.  When I started using the program, I asked our billing company to generate an Excel spreadsheet of the demographic and insurance data for all our practice patients from the past 3 years.  We sent this to Practice Fusion, through the application, and a few days later it was searchable online.  This eliminated a lot of data entry when existing patients returned.

Cons:

  1. Billing.  This is where I think Practice Fusion could be improved as billing is not well integrated.  I bought a practice that was using an outside billing company. My partner would send them paper encounter forms and they would process his claims.  They charged 4.5% for this service.  Practice Fusion has paired with a service called Kareo, which you pay for like any other billing company, but you can directly ship your superbills to them through the web interface.  I can’t comment on how well this works because I elected to stay with our billing company when I read online reviews for Kareo, which were positive but full of problems with slow support and poor EHR integration.  I may be paying more, but I know my bills are getting sent properly.  I currently send superbills in Practice Fusion, which are just filed as messages with ICD-9 and CPT codes in each patient’s chart.  Modifiers must be added manually as notes below the codes.  The billing company then accesses these messages each day through Practice Fusion and processes the claims.  My billing company was very flexible and able to accomodate me, and I think they actually like how it is working out.  I have to do all the coding as I don’t have a dedicated coder working for me.  I think they don’t invest in improving this because they want you to just sign up with Kareo instead.
  2. User Interface.  This is a soft con.  Most of the UI is great, but there are a few things that bother me, such as the time it takes to upload documents.  Uploading documents could be better streamlined, such as a bulk upload.  As it stands, each document must be uploaded one by one, with about 6 clicks necessary to fill in all the metadata identifying the type of document and associating it with the patient. Insurance information also can be difficult to fill in as there is no easy way to document the address and phone number of the insurance carrier, however, after a while you have most of your common payers entered and you can simply choose them from a list.
  3. Lack of a mobile solution.  Many EHRs have implemented tablet apps, which would allow the physician to wander room to room without having to log in and out of the system.  The constant logging in eats up a minute or two each time, which adds up after 30 patients.  Practice Fusion has announced they have an iPad app in the works and I’m hopeful it will be here soon. If the new iPad’s dictation features (iPad 3) could be used for charting, you could truly speed up your note-taking.  They currently recommend you use an app called LogMeIn to view and manipulate your computer desktop on your iPad, which works fine for checking your schedule, but is too clunky for charting or anything else more intense. The company has received about 30 million in funding in the past year, so they are hopefully hiring lots of smart engineers to ramp up innovation and smooth out the bugs. 
  4. No integrated drawing application or photo management.  There is no way inside the program to draw and save this to the chart.  I don’t rely on drawings much, so this doesn’t bother me. I prefer photos and have developed my own way of managing these (I use Adobe Lightroom to manage them and produce PDF composites, which can be uploaded to the system and easily printed, faxed or emailed.  I use a few hard-drives for external back-up of the originals.)
  5. Not optimized for any particular specialty.  If you have a lot of recurring patient data, such as monthly IOPs in bad glaucoma sufferers, there isn’t a way to graph it or easily follow it.  My profession, oculoplastic surgery, doesn’t require this so it isn’t a problem for me.  When looking at one chart, all the previous notes are listed in the sidebar by date and you can hover over them and see the entire note, which is how I scan previous visits quickly.  Having all that fancy database capability like Medflow and others offer is very important to some.

I’m sure there are other quirks of the system you would find, but none have been deal-breakers for me.  I have looked around at a few other cloud-based EHRs, such as DrChrono, which is centered around the iPad for charting and check-in.  It has a free version, but to get real functionality you would need to opt for one of their premium services which cost up to $399/mo. per physician. This includes billing.  Their user-base is only around 15,000 people, whereas Practice Fusion now claims over 150,000.  I feel a litte more confident sticking with a company that is more likely to be around in 5 years and I feel it will only get better in the coming months.  If not, changing to a different system would be easier than had I committed to a more expensive software and hardware.

Two caveats I must mention are these:

  1. You don’t have physical control of your data.  The data is stored off site in encrypted servers with several layers of back-up and is all HIPAA compliant and such (I’m told by their representatives), but at the end of the day, they control the data.  I’m not particularly bothered by this because I feel a server sitting in my office would be at risk of damage or theft and no data can ever be 100% secure.  Practice Fusion ultimately has a lot more to lose from a data breach or loss than I do and they have resources to prevent that from happening. 
  2. They make their money off of advertising and potentially sharing anonymized patient data (last I read they haven’t made money from this, but you agree to let them use it by joining the service).  The ads are very unobtrusive and most often are either from Practice Fusion itself or Dragon Medical dictation.  I can’t recall seeing any ads for pharmaceuticals or other companies trying to influence practice patterns, although they will probably creep in eventually.  You have the option of using ad blocking extensions in your browser, but I feel in this case I owe it to them to see their ads as they are what pay for the service.

In conclusion, both I and my staff are very happy with Practice Fusion.  I think this is the future of EHR technology as it takes many of the pains of running a computer network out of the hands of physicians and just leaves them with the pains of documentation, which are inescapable.  If you are in the market for a new EHR, you owe it to yourself to try out Practice Fusion.  You can create an account by going to their website.  If you are using a cloud-based EHR in your practice, let me know in the comments, or directly at [email protected].